Case Study of Rheumatoid Arthritis

Posted on
4/04/07

This is a 42-year-old man who was diagnosed with rheumatoid arthritis (RA) and psoriatic arthritis 2 years prior by the rheumatologist and is being followed by this same doctor. He has been on anti-inflammatories for about 6 months with no real relief. As a result, methotrexate (MTX) 20 mg/week was started and tapered down to 15 mg/week as symptoms improved. After about 6 months, his symptoms worsened. He reported joint stiffness and redness and swelling in fingers, an MRI noted significant bone loss. The rheumatologist wanted to start him on a biologic, but had difficulties with the insurance company authorizing treatment because the letter of medical necessity was not appropriately written. During this time, the methotrexate dose was again increased to 20 mg/week with some relief.

In April of 2005 the patient decided to leave his current rheumatologist and find a new one at the local university medical center. He did so and was enrolled in a clinical trial study for RA and psoriatic arthritis. He was immediately started on monthly biologic infusions and was kept on MTX 1st at 15 mg/week than increased to 20 mg/week. His medications at that time included: MTX 15 mg/week then increased to 20 mg/week, leucovorin calcium 5 mg PO QD, folic acid 1 mg daily, levothyroxine sodium 0.05 mg PO QD, infliximab infusions every 6 to 8 weeks, and quinine sulfate once daily.

He was going along great until January 2006 when he had a disease flare, which was treated with an injection of dexamethasone. Later that month he developed severe bronchitis with asthma-like symptoms. He was placed on levofloxacin, a methylprednisolone dose pack and an albuterol/ipratropium inhaler. He developed fatigue along with a persistent cough and still received his scheduled dose of infliximab. One month later (in early March 2006) he had increased congestion, fatigue and a bad cough. He went to his PCP who diagnosed him with a severe sinus infection and placed him on amoxicillin/clavulanate for 14 days. Approximately 9 days later he developed severe diarrhea and began to lose weight. The PCP felt it was not related to the antibiotics and asked him to finish the complete course. The day after his conversation with the PCP, he was unable to work because he was weak, nauseous and unable to keep fluids down. He went to the ER and was admitted to the telemetry unit with a WBC of 22,000, dehydration, vomiting, vertigo and heart block. While in the ER, his EKG revealed an arrhythmia related to pre-existing first-degree heart block. A course of IV therapy was begun with anti-emetics. He also had x-rays and laboratory monitoring. He was diagnosed and treated for Clostridium difficileand colitis, and his MTX doses were held during the 4-day hospitalization.

A CT scan of the lung was done and it revealed a small mass in the right upper lobe, and a PET scan was then scheduled as an outpatient test. Upon discharge he was instructed to follow-up with the PET scan, and with a gastroenterologist and a pulmonologist. The pulmonologist read the report of the PET scan and recommended a bronchoscope, and scheduled pulmonary function tests for the next month. The results of the pulmonary function tests were almost normal, so it was recommended that a repeat CT scan and chest x-ray be done in June 2006, prior to the scheduling of the bronchoscope. The patient was prescribed an inhaler for adult- onset asthma.

About the same time in mid-March 2006, he developed increased lethargy and became unconscious for approximately 15-20 seconds upon getting up from a supine position. He was taken to the ER where he was found to have acute pancreatitis. An EKG showed slow rhythm and he was placed on telemetry again for 5 days. He was seen on consult by a cardiologist and was treated and scheduled for outpatient follow-up tests. While in the hospital he had physical therapy due to increased stiffness and weakness. He developed shoulder pain which was treated with meperidine and promethazine which he received via IV push, to which he became unresponsive. Naloxone was administered and he responded. Infliximab infusions were scheduled to resume in the next few weeks. However, in the interim, his PCP determined that the pancreatitis was due to the infliximab infusion. During his entire course of hospitalizations, his rheumatologist was advised of his progress. He was sent home with instructions for a follow-up for a tilt-table test. The outcome of that test revealed 1st-degree heart block. The patient was cleared by the cardiologist and asked to follow-up in 3 months.

In May 2006, the patient had resumed infusion of infliximab every 6 weeks with laboratory testing completed prior to each infusion. In June 2006, the patient returned to work part-time. In July 2006 he had a follow-up with his pulmonologist for a repeat chest x-ray and CT scan with a confirmation of no increase in nodule. At the time, the impression of the nodule was to rule-out an RA nodule versus scarring from previous bouts of pneumonia. The follow-up schedule was to consider bronchoscopy in 3 months if there was no change in his respiratory symptoms. His pulmonary function tests were within normal limits and he was released to go back to working full-time.

In October 2006 upon follow-up with the pulmonologist, the patient had no change in his respiratory status and no change in his chest x-ray. Therefore it was deemed that there was no need for bronchoscopy. The final diagnosis by the pulmonologist was an RA nodule. An MRI completed at that time showed reversal of bone loss with infliximab. A subsequent follow-up with the pulmonologist in March 2007 revealed no change in his respiratory status or chest x-ray results. The plan was to again follow-up with the pulmonologist in 3 months. The patient continues to receive the following medications: MTX 20 mg by mouth weekly, leucovorin calcium 5 mg orally qd, quinine sulfate 1 tablet po daily, and an infliximab infusion every 6 weeks.